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Employee Handbook of the Royal College of Physicians of Ireland

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RCPI Policy Group on Alcohol

Reducing Alcohol Health Harm

April 2013

1

RCPI Policy Group on Alcohol: Reducing Alcohol Health Harm Policy Statement

Table of contents

1 Executive Summary .................................................................. 2

2 RCPI Policy Group on Alcohol ..................................................... 5

3 The Problem ........................................................................... 6

3.1 Alcohol Consumption and Irish Society ............................................. 6

3.2 Drinking Trends ........................................................................ 6

Economic Contribution of the Alcohol Industry ............................................. 8

3.3 Alcohol Consumption and Health Harm ............................................. 9

Mortality ......................................................................................... 9

Morbidity....................................................................................... 10

3.4 Personal, Family and Social Harms ............................................... 13

3.5 Economic Costs of Alcohol ......................................................... 14

4 Current Government Policy ...................................................... 16

5 The Solutions - Societal/Public Health ......................................... 17

5.1 Minimum Pricing ..................................................................... 17

5.2 Reduced Availability ................................................................. 19

5.3 Changing Culture .................................................................... 20

5.4 Alcohol Consumption Guidelines .................................................. 22

6 The Solutions - Medical Supports ............................................... 23

6.1 Alcohol Screening and Brief Interventions ........................................ 23

6.2 Integrated Model of Care ............................................................ 25

6.3 Research Funding ................................................................... 27

7 Members of the RCPI Policy Group on Alcohol .............................. 28

8 Appendix- Factsheet on Alcohol Health Harm ................................ 29

9 References ........................................................................... 33

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Reducing Alcohol Health Harm

1 Executive Summary

1.1 As part of the Royal College of Physicians of Ireland’s (RCPI) aim to play a

proactive role in the development of healthcare policy in Ireland, it has

convened a number of issue-focused policy groups that allow medical and

other experts to meet and to discuss healthcare matters of concern to

healthcare providers and the general public. In response to the increasing

levels of alcohol-related harm observed in recent years in Ireland, RCPI

established a Policy Group on Alcohol in 2012. This policy group is cross-

speciality and is focused on highlighting alcohol harm, proposing solutions to

reduce this harm, and influencing decision makers to take action to address

the damage caused by alcohol misuse.

1.2 High levels of alcohol consumption and a high prevalence of binge drinking,

especially among young people, have serious health implications. These

health implications range from alcoholic liver disease to increased risk of

various forms of cancer. Alcohol misuse is also associated with family and

social harms, and costs the state vast amounts of money and resources.

1.3 Despite the high societal and economic cost of problem alcohol use in

Ireland, actions to reduce alcohol consumption and to address harmful

drinking patterns have, to date, been limited. The Royal College of Physicians

of Ireland believes that there are proven solutions to this problem which

should be implemented immediately for the benefit of the individual and for

society in general.

1.4 Many of these solutions have already been outlined in the Department of

Health 2012 Steering Group Report on a National Substance Misuse Strategy

i(NSMS), and the RCPI Policy Group on Alcohol urges the Government to take

action to implement these recommendations.

1.5 In addition, the group proposes a number of actions within the health system

aimed at reducing damage to health caused by alcohol misuse.

iReferred to throughout this document as NSMS report

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1.6 Overall recommendationiis:

Summary of Key Recommendations

Societal/Public

Health Solutions:

Minimum Pricing

Alcohol Availability

Changing the

Culture of Alcohol

Consumption

Guidelines on

Alcohol

Consumption

We support the introduction of minimum pricing to

prevent the sale of cheap alcohol.

We support this recommendation of the Steering Group

on a National Substance Misuse Strategy.

Minimum pricing will not affect the price of pint in the

pub. Rather it will target off-trade sales where the

cheapest alcohol is sold.

We support measures to reduce the availability of alcohol

Number of alcohol outlets should be reduced.

Alcohol sales in off-trade outlets should be managed

better and low cost sales promotions and discounts

should be strictly controlled.

Alcohol should be sold in zoned areas in mixed retail

outlets.

Sale and supply to minors should not be tolerated and

there should be punitive fines with rigorous

implementation and oversight.

We support measures to change the culture of excessive

alcohol consumption.

Alcohol advertising/marketing encourages people,

particularly younger people, to consume alcohol and

contributes to a culture of acceptability in relation to

excessive alcohol consumption.

Alcohol sponsorship of sports events and organisations

should be phased out.

Stricter controls should be introduced on where and

when alcohol advertising is placed, with a view to

limiting exposure of minors to alcohol marketing.

We support dissemination of guidelines on low risk levels

of alcohol consumption.

Weekly low-risk consumption guidelines as outlined in

NSMS should be adopted.

RCPI will also play its part in developing and

implementing more detailed clinical guidelines and

ii See appendix- Factsheet on Alcohol Health Harm for summary of evidence and

recommendations.

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Medical/ Health

System Supports:

Alcohol Screening

and Brief

Interventions

Model of Care for

Alcohol-related

Health Problems

Funding for

Research

clinical information to provide extra information for the

population in interpreting these guidelines

Labeling on alcohol products sold in Ireland should show

units of alcohol, grams of alcohol per container, calorific

content and health warnings.

We propose that Alcohol Screening and Brief Interventions

be embedded in clinical practice.

Currently no formal guidelines for screening and BIs in

acute hospitals.

Screening for hazardous, harmful and dependent

drinking should be embedded into clinical care.

Screening should be linked to the provision of brief

interventions by trained health care workers.

There should be adequate access to tier two, three and

four alcohol services for patients not responding to brief

intervention.

We recommend that an integrated model of care be

developed for treatment of alcohol-related health

problems.

Clinical guidelines for treatment of alcohol-related

health problems should be developed for healthcare

professionals across all relevant sectors of the health

and social care system.

Links between alcohol treatment services in hospitals

and the community should be strengthened.

Aftercare in the community should be supported

particularly with respect to relapse prevention.

The referral relationship between primary and secondary

care needs to be improved.

Outpatient detoxification services to be established.

Alcohol-related mental illness should be included within

the model of care.

Acute hospitals should have an alcohol team led by a

consultant or senior nurse, and incorporating at least

one alcohol nurse specialist.

We recommend that the Government allocate specific

funding for research into alcohol-related harms,

especially alcoholic liver disease.

There is very little funding available for research into

alcohol-related harm, especially alcoholic liver disease.

Levies on the alcohol industry should be used to support

this research.

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2 RCPI Policy Group on Alcohol

2.1 As part of the Royal College of Physicians of Ireland’s (RCPI) aim to play a

proactive role in the development of healthcare policy in Ireland, it has

convened a number of issue-focused policy groups that allow medical and

other experts to meet and to discuss healthcare matters of concern to

healthcare providers and the general public. These policy groups provide

evidence-based position papers that outline the issue(s) and propose steps to

address the issue(s).

2.2 In keeping with this aim, RCPI established a Policy Group on Alcohol in 2012

to reduce the damage to health caused by problem alcohol use. One of the

main drivers for establishment of this policy group is the dramatic increase

observed by physicians in recent years in alcohol-related morbidity and

mortality, especially in younger people.

2.3 The remit of the policy group is to: highlight the rising levels of alcohol

health harm in Ireland; propose evidence-based solutions to reducing this

harm; influence decision-makers to take positive action to address the

damage caused by problem alcohol use.

2.4 The policy group’s remit will be accomplished by producing evidence-based

policy statements which provide an expert view on the clinical priorities

relating to alcohol and alcohol-related harm in Ireland by outlining the issues,

the challenges and providing solutions.

2.5 In addition, the policy group plans on raising awareness of alcohol health

harm through media campaigns and public meetings, and considering how

outcomes of the evidence-base can be translated into postgraduate medical

training and education.

2.6 The policy statements and awareness of alcohol health harm will add to the

national debate on the issue and, importantly, will recommend tangible

actions to reduce damage to health caused by alcohol misuse.

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3 The Problem

3.1 Alcohol Consumption and Irish Society

3.1.1 As a nation, the Irish are heavy alcohol consumers. This should come as no

surprise, as the image of the Irish as a nation of drinkers is propagated

directly and indirectly worldwide, For example, Guinness and ‘Irishness’

have become intrinsically linked; the visit of a foreign dignitary is

frequently not complete without a photo of them drinking a pint of ‘the

black stuff’; and the Guinness Storehouse was the most popular fee-

charging tourist attraction in the country in 2011.1 Part of the very appeal

of Ireland as a tourist destination lies in the notion of ‘craic’, often to be

found in a cosy pub, traditional music playing, a turf fire blazing, as the

visitor is enveloped in a truly Irish welcome.

3.1.2 The place of the pub as a centre for Irish social life is indisputable. There is

scarcely a small village or parish in the country that does not have a ‘local’.

Irish people go to the pub for various reasons: to celebrate; to

commiserate; to welcome visitors; to pass the time; to meet friends; and to

befriend strangers.

3.2 Drinking Trends

3.2.1 While the pub continues to play a central role in community and social life,

recent years have seen a shift from alcohol sales in pubs to sales in the off-

trade sectoriii. Between 1998 and 2010 there was a 161 per cent increase in

the number of full off-licences, while pub licences decreased by 19 per cent

over the same period.2 Supermarkets, convenience stores and even petrol

stations sell alcohol, often at discounted prices. The abolition of the

Restrictive Practices (Groceries) Order in 2006 allowed for a variety of

goods to be sold below cost price, including alcohol.

3.2.2 Ireland is not the highest consumer of alcohol in the EU. At 11.9 litres (2010

figures) per capita, Ireland ranks 6th in terms of pure alcohol consumption

iii Off-trade refers to off-licences and mixed retail outlets; on-trade refers to bars,

restaurants etc.

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per capita (>15 years), after Latviaiv, Romania, Austria, Lithuania and

France.3 This amount is still substantially higher than the European average

of 10.7 litres and 16 per cent higher than our UK neighbours.4 It is also

substantially in excess of the reduced alcohol consumption target of 9.2

litres per capita as specified in the ‘Healthy Ireland’ framework, recently

launched by the Department of Health.5 It should be noted that adjustments

to exclude all those under the age of 18 would give a recommended per

capita (≥18) consumption of 6.91 litres.

3.2.3 There are a relatively high number of abstainers in Ireland. A European

survey on attitudes to alcohol revealed a rate of abstention (in the 12

month period preceding the survey) of 24 per cent. This compares with

abstention rates of 19 per cent and 17 per cent in the UK and France

respectively.6 Given this high rate of abstainers, actual alcohol consumption

per drinker is greater than the 11.9 litres referred to above, and targets for

reduced consumption should take this into account.

3.2.4 Looking beyond overall levels of consumption to drinking patterns,

according to a European survey conducted in 2009, Ireland has a higher

prevalence of binge drinking than any other EU country with 44 per cent of

drinkers stating that they binge drinkv on a regular basis.7 It is worth noting

that this represents a decrease from previous years; for example WHO data

from 2002 indicated binge drinking levels then were extremely high at 55.6

per cent of male drinkers and 20.2 per cent of female drinkers.8 Overall

consumption has also declined in recent years since a peak of 14.2 litres per

capita in 2002.9 These statistics on declining rates of alcohol consumption

are sometimes cited as indicators that the attitude to alcohol as a nation is

changing and improving. However, it is more likely that this change is

related to reduction in income rather than changes in attitude. Notably,

from 1980 to 2010, average alcohol consumption decreased in Europe by an

average of 15 per cent, while consumption in Ireland over that period

increased by 24 per cent.10 In fact, since 1963, alcohol consumption per

adult in Ireland has almost doubled.11 Arguments against more stringent

iv Luxembourg has highest recorded per capita consumption but is disregarded here because of the high

volume of purchases by non-residents in this country. v 5 or more drinks per drinking occasion

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alcohol policies which cite the Irish ‘drinking culture’ as an integral part of

historical Irish identity often do not acknowledge this relatively recent

increase in consumption.

3.2.5 In terms of total consumption, and frequency of binge drinking, Irish men

drink more, and engage in binge drinking more often than women.12

However a higher proportion of Irish women (77 per cent) drink alcohol

when compared with other European countries (68 per cent).13

3.2.6 The relatively high proportion of abstainers, combined with high levels of

binge drinking indicates an inability to adopt a moderate consumption

pattern. The highest proportion of binge drinkers is in the 18-29 age group,

and although instances of binge drinking were decreasing among other age

groups, among 18-23 year olds, binge drinking was still increasing in 2007

Young people were also more likely to exceed the weekly recommended

limit. 14

3.2.7 Because of the relatively high per capita consumption of alcohol in Ireland,

the even higher consumption per drinker given our high rate of abstainers

and the high prevalence of binge drinking, the effects of alcohol on the

health and social fabric in Ireland are considerable.

Economic Contribution of the Alcohol Industry

3.2.8 Alcohol has a prominent place in the Irish economy. The hospitality industry

provides an estimated 50,000 full time equivalent jobs, the majority of

which are in the on-trade sector. The turnover of the industry in 2008 was

approximately €2.95bn, representing 2.4 per cent of total manufacturing

turnover.15 In addition, alcohol manufacturing and retail generated €2bn in

VAT and excise revenues in 2008.16

3.2.9 Surveys show that the average Irish adult spends between €130017 and

almost €2000 a year on alcohol.18 This upper figure represents almost 5 per

cent of total household expenditure, and is greater than average household

expenditure on fuel and light or clothing and footwear.19

3.2.10 It is worth noting that many arguments against increased controls on the

alcohol industry point to the significant loss to Government revenue and

economic output that would result if alcohol consumption decreased. This

argument however, does not take into account that consumers would spend

money on other services and goods even if they reduce spending on alcohol.

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In addition, there is a substantial economic cost associated with alcohol-

related harm which should also be taken into account (see section 3.5).

3.2.11 Notwithstanding the significant economic contribution of the drinks

industry, and the social and societal function of alcohol in Ireland, alcohol

is not an ordinary commodity, and should not be treated as such. Failure to

recognise the multiple harms associated with alcohol consumption causes

severe harm on an individual, family and societal level.

3.3 Alcohol Consumption and Health Harm

“Alcoholic beverages are items of consumption with many customary uses and are

commodities important to many people’s livelihood. But social customs and

economic interests should not blind us to the fact that alcohol is a toxic

substance. It has the potential to affect adversely nearly every organ and system

of the body. No other commodity sold for ingestion, not even tobacco, has such

wide ranging adverse physical effects”.20

Mortality

3.3.1 Alcohol is a psychoactive substance that has health impacts on the

individual, which vary depending on levels and patterns of consumption. In

large amounts, alcohol has a toxic effect and can be fatal. Long term heavy

consumption of alcohol is associated with mortality from wholly alcohol

attributable diseases such as alcoholic liver disease, the majority of these

deaths being from alcoholic liver cirrhosis.21

3.3.2 For the vast majority of people, consumption of alcohol above the low risk

guidelines has a negative health impact. Contrary to the popular belief that

a glass of wine a day is good for your health, any health benefit from

alcohol consumption is limited to a very small segment of the population. A

recent study examining alcohol attributable mortality in Ireland showed

that net benefit from alcohol consumption was limited to people over 75

years of age.22

3.3.3 According to the World Health Organisation (WHO), almost 4 per cent of all

deaths worldwide are attributed to alcohol. This is greater than deaths

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caused by HIV/AIDS, violence or tuberculosis.23 A European report on

Alcohol and Public health estimated that 1 in 4 deaths in young European

males were due to alcohol.24

3.3.4 In Ireland, between 2000 and 2004, it was estimated that 4.4 per cent of

deaths were caused by alcohol. This figure includes deaths from chronic

alcohol-related conditions such as alcoholic liver disease and liver cancer,

and accidental and non-accidental deaths while under the influence of

alcohol.25 A report by the National Drug Related Deaths Index which focuses

on deaths in alcohol dependent people found that in 2008, there were 88

deaths every month which were directly attributable to alcohol.26 The same

report also showed that between 2004 and 2008, alcohol caused nearly

twice as many deaths as all other drugs combined.27

3.3.5 Alcohol is strongly linked to suicide, particularly suicides in young men.28 A

2006 study showed that more than half of all people who died from suicide

had alcohol in their blood.29 From 2000 to 2004, alcohol was estimated to

be the major contributing factor in 823 suicides.30 There is a complex link

between alcohol misuse, unemployment and suicide. A WHO report from

2011 focusing on mental health and the economic crisis predicted that the

economic crisis may lead to increased suicide and alcohol-related death

rates.31

Morbidity

“The WHO has attributed 60% of the disease burden in Europe to seven leading risk

factors: hypertension, tobacco use, alcohol misuse, high cholesterol, being

overweight, low fruit and vegetable intake and physical inactivity”.32

3.3.6 Alcohol is fully (100 per cent) attributable as a cause in 9 disease categories

including alcoholic liver disease.33 Alcoholic liver cirrhosis is the form of

liver disease most often associated with alcohol misuse and cirrhosis

mortality has traditionally been used as an indicator for tracing the

health consequences of alcohol misuse in Europe.34

3.3.7 Members of the RCPI Policy Group on Alcohol have observed a dramatic

increase in (alcohol-related) severe morbidity and mortality in younger

people. Death from alcohol cirrhosis is no longer limited to older men as

was once the case. It is now commonplace for physicians to see young men

and women in their 20s and 30s dying in acute hospitals from liver disease

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secondary to alcohol. Analysis of data from Ireland’s Hospital In-Patient

Enquiry (HIPE) system confirms that chronic alcohol-related conditions are

becoming increasingly common among young age groups. In Ireland between

1995 and 2007, the rate of discharges for Alcoholic Liver Disease increased

by 247 per cent for 15-34 year olds, and by 224 per cent for 35-49 year

olds.35

3.3.8 Mortality related to cirrhosis, the commonest cause of which is alcohol,

doubled from 1994 to 2008 and hospital admissions in Ireland for alcoholic

liver disease almost doubled between 1995 and 2007.36 This increase

appears to be directly related to increased alcohol consumption and

changes in drinking patterns, especially in relation to binge drinking. In the

same period, 72 per cent of deaths from alcoholic liver disease were in

patients younger than 65 years of age indicating that this is a significant

cause of premature mortality.37 Similarly to Ireland, the UK has also

registered an increased incidence of alcoholic liver disease38 in recent

decades, but in most other European countries the prevalence of alcoholic

liver disease and associated mortality is falling.39

3.3.9 Patients with liver disease with or without alcoholic hepatitis impose

significant demands on hospital resources and frequently require a

multidisciplinary approach in an intensive care setting.

3.3.10 Alcohol-related disorders accounted for 1 in 10 first admissions to Irish

psychiatric hospitals in 2011.40

3.3.11 Even at relatively low levels of consumption, alcohol increases the risk of

many medical conditions. Alcohol is classified as a group 1 carcinogen and it

is one of the most important causes of cancer in Ireland being a risk factor

in 7 types of cancer. The link between alcohol and cancer of the larynx,

pharynx and oesophagus is the greatest, as there is more than 100 per cent

increase in risk from an average consumption of 50g of pure alcohol per

day.41 For female breast cancer there is a slight increased risk with

consumption of any amount of alcohol but for those women consuming >45g

of pure alcohol per day, each additional 10g of alcohol per day is associated

with a 7 per cent increased risk.42 For colorectal cancer, consumption of

50g of pure alcohol per day increases the risk by 10-20 per cent.43 The

National Cancer Control Programme (NCCP) conducted research in 2012 to

calculate Ireland’s overall and organ-specific, cancer incidence and

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mortality attributable to alcohol consumption and found that approximately

5 per cent of newly diagnosed cancers and cancer deaths are attributable to

alcohol i.e. around 900 cases and 500 deaths each year. The greatest

impact was on organs of the upper aero-digestive tract. Cancer risk due to

alcohol is deemed to be same, regardless of the type of alcohol consumed,

and even drinking within the recommended limits carries an increased

risk.44

3.3.12 Drinking alcohol while pregnant can cause a range of birth defects, known

as Foetal Alcohol Spectrum Disorders (FASD). Signs of FASD include:45

Distinctive facial features

Deformities of joints, limbs and fingers

Slow physical growth before and after birth46

Vision difficulties or hearing problems

Small head circumference and brain size (microcephaly)

Poor coordination

Mental retardation and delayed development

Learning disorders

Abnormal behaviour, such as a short attention span, hyperactivity,

poor impulse control, extreme nervousness and anxiety

Heart defects

3.3.13 There is also evidence to link alcohol consumption in pregnancy to

miscarriage.47 Despite this, a recent Irish study revealed that among a

sample of women who had a positive pregnancy test, more than half drank

alcohol subsequently, some to excess (>50g pure alcohol per week).48 More

than a third of pregnancies among women in Ireland are unplanned,

resulting in unintended excess alcohol intake in the periconceptional

period.49 In addition binge drinking is highly prevalent among women of

reproductive age and is associated with unplanned intercourse, sexually

transmitted infections and unplanned pregnancy.

3.3.14 It is worth noting that whilst there is conflicting evidence on the extent of

harm caused to the foetus by alcohol during pregnancy, advice from the

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Department of Health and other national health departments is that alcohol

in pregnancy should be avoided. 50 51

3.3.15 Because the brain in still developing, drinking in adolescence has the

potential to cause detrimental effects, including neurocognitive

impairment.52 Evidence also suggests that adolescents who misuse alcohol

are more likely to suffer side effects such as appetite changes, weight loss,

eczema, headaches and sleep disturbance. Younger people are also affected

by the same chronic diseases and conditions associated with excess alcohol

consumption in adults, and deaths from liver disease are now occurring at

younger ages.53

3.4 Personal, Family and Social Harms

3.4.1 These health harms are only part of the problem related to alcohol. There

are wider personal and family impacts which have a negative effect on both

the individual and on society.

3.4.2 Excessive alcohol use frequently leads to unsafe sex resulting in unplanned

pregnancies and sexually transmitted diseases. A recent report from the UK

highlighted that 82 per cent of 16–30-year-olds reported drinking alcohol

before sexual activity and that young people who were drunk the first time

they had sex, were less likely to use condoms.54 The study also showed that

people aged 16–24 are among the highest consumers of alcohol (in the UK)

and have the highest rate of sexually transmitted infections. A number of

other studies show associations between alcohol consumption and Sexually

Transmitted Infections (STIs).55 In an Irish study 45 per cent of men and 26

per cent of women stated that alcohol consumption contributed to having

sex without using contraception.56

3.4.3 Domestic abuse and child abuse is often linked to harmful alcohol use. It is

estimated that 16 per cent of child abuse and neglect cases are associated

with adult alcohol problems57 and that 1 in 11 Irish children are negatively

impacted by a parent’s drinking.58 Alcohol misuse is often a factor in martial

disharmony and break-up and in cases of domestic violence.59

3.4.4 Links between alcohol and crime are well established. Intoxication of both

perpetrator and victims has been noted in a high percentage of instances of

homicide and sexual assault. Public disorder offences which are alcohol-

related are common, as are drink driving offences. 60

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3.4.5 A Rape and Justice in Ireland briefing paper by the Rape Crisis Network

outlined research which indicates that decisions on the consumption of

alcohol made by both men and women can have the effect of facilitating

the incidence of rape and make the detection and prosecution of rape more

difficult. Alcohol consumption also affects decisions on whether to report

alleged rapes. 61

3.4.6 Any level of blood alcohol concentration is associated with a higher risk of

road traffic accidents. From 2003 to 2005, over half of all drivers fatally

injured in RTAs in Ireland had alcohol in their blood, with younger drivers

(20-24 years) more likely to be over the legal limit. Random alcohol testing

introduced in 2006 has been successful in reducing road deaths.62

3.4.7 Similarly, alcohol consumption increases the risk of other types of

accidents. In 2002, 1 in 4 injuries presenting to accident and emergency

departments was related to alcohol and over half of these injuries occurred

in people younger than 30 years of age. 63

3.4.8 Excessive alcohol consumption by young people is particularly worrying, as

early onset alcohol use increases the risk of problem alcohol and drug use

later in life.64 Irish adolescents with serious drug and alcohol problems had

commenced alcohol use at a much earlier age than their counterparts

without significant drug or alcohol problems.65 There is also evidence to

suggest that alcohol consumption has a negative effect on educational

performance.66

3.5 Economic Costs of Alcohol

3.5.1 The information in the preceding section shows that alcohol consumption

has a health and wellbeing cost to the individual, and that alcohol causes

behaviour which can be harmful to both the person consuming the alcohol

and others they come into contact with. Interventions which reduce alcohol

consumption and/or risky patterns of consumption would therefore have a

positive impact on the wellbeing of Irish society.

3.5.2 Given the economic and employment role of the alcohol industry, the

taxation revenue generated by alcohol sales, and the probability that

interventions to reduce alcohol consumption will require a financial

investment, it is important to understand the financial cost of alcohol to

the State at present.

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3.5.3 Alcohol costs the State vast amounts of money and resources. There are

direct costs to the health care system associated with treating alcohol

dependency and effects of harmful alcohol consumption. Alcohol is also

recognised as a causal and contributory factor in various incidences of

crime, which carry a financial cost to the State. Other costs relate to road

accidents, suicide and alcohol-related premature mortality.

3.5.4 There are also substantial business costs associated with direct health-

related consequences of alcohol misuse. Alcohol consumption can impact

work performance and is frequently the cause of absenteeism and physical

injuries in the workplace.67

3.5.5 A study commissioned by the HSE examined costs of harmful alcohol use in

Ireland in 2007. It estimated that the overall cost in 2007 was €3.7bn or 1.9

per cent of total GNP.68 This figure is 1.8 times the amount made by the

Government in alcohol-related excise and VAT revenues in 2008. Some of

these costs are broken down below.

o Costs to the health system were €1.2bn

o Alcohol-related crime costs €1.19bn

o Alcohol-related road accidents cost €526m

o Loss of economic output due to absenteeism cost €330m

Alcohol is associated with approximately 2000 beds being occupied every

night in Irish acute hospitals.69 As mentioned previously, a quarter of all

injuries presenting to accident and emergency were alcohol-related, and

alcohol-related admissions to acute hospitals doubled between 1995 and

2008.70

Despite the high societal and economic cost of alcohol misuse in Ireland, actions to

reduce alcohol consumption and to address harmful drinking patterns have to date

been limited. The RCPI Policy Group on Alcohol believes that there are proven

solutions to this problem which should be implemented immediately for the benefit

of individual consumers and for society in general.

16


4 Current Government Policy

4.1 Current Government policy in relation to alcohol is ambiguous. While there is

legislation from the Department of Justice relating to licensing and public

order, there is no legislation on the statute books from the Department of

Health in relation to alcohol.

4.2 The Department of Health published the report of the Steering Group of the

National Substance Misuse Strategy in January 2012. This report has 45

recommendations; 15 of these are in relation to supply control, 7 are in

relation to prevention, 20 are in relation to treatment and rehabilitation and

3 are in relation to research. A range of agencies has been assigned primary

responsibility for the different recommendations. It had been stated that a

Memorandum for Government in relation to a number of these

recommendations would be presented in June 2012. This did not happen and

the report has been referred to the Oireachtas Committee on Health. This

same Oireachtas Committee produced a report in December 2011 outlining a

broad public health approach to alcohol policy.71 Both reports recommended

bringing forward legislation, but this has yet to be done by the Houses of the

Oireachtas.

4.3 Within Government there appear to be differing views on the Steering Group

report. It is deeply concerning that there appears to be ambiguity at

Government level on the implementation of the recommendations of this

report.

4.4 In March 2013, the Minister for Health stated that specific proposals based on

the recommendations for the Steering Group report would soon be brought

forward for consideration by Government. The minister also indicated his

support for minimum pricing, one of the key recommendations of the report.

4.5 The ‘Healthy Ireland’ framework launched in March 2013 refers to the

National Substance Misuse Strategy report and reaffirms Government

commitment to reducing alcohol consumption.

4.6 The policy group welcomes the recommendations of the Steering Group

Report. The following section summarises what the RCPI Policy Group on

17


Alcohol believes are the important actions which should be enacted or put

into practice, with reference to recommendations from that report.

4.7 The actions/solutions proposed by the RCPI Policy Group on Alcohol fall into

two separate categories. The first are solutions to be taken at the societal or

public health level. The second category refers to actions which should be

taken within the health system to address alcohol-related harm.

5 The Solutions - Societal/Public Health

The RCPI Policy Group on Alcohol strongly believes that from a societal/public

health perspective, there are four areas where concrete, immediate actions could

be put in place to limit alcohol consumption, thereby reducing alcohol-related

harm.

5.1 Minimum Pricing

We support the introduction of minimum pricing to prevent the sale of cheap

alcohol.

5.1.1 We support the recommendation of the NSMS Steering Group report that

alcohol should be made less affordable and less available. The report

recommended that this should be done through excise duties and minimum

pricing. In December 2012 the Government increased excise duty on a pint

of beer or cider and a standard measure of spirits by 10 cents, and the duty

on a 75 cl. bottle of wine by €1.

5.1.2 These measures do not sufficiently address the issue of reducing the

proliferation of cheap alcohol. Alcohol has become much more affordable in

recent years. Between 2002 and 2007 there was a 44 per cent increase in

the quantity of lager which could be purchased with one week’s disposable

income.72 Alcohol Action Ireland highlights that it is now possible at current

prices, for a women to reach her weekly recommended low risk limit for

€6.30, while a man can reach his low risk limit for less than €10.73

5.1.3 Research shows that alcohol, like other commodities, concurs with a

fundamental law of economics which maintains that demand for a product

falls as its price rises.74 Experience in Ireland also supports this; excise

increases in 2003 and 2002 on spirits and cider respectively, showed a

18


corresponding decrease in consumption.75 Furthermore, alcohol price

increases have been shown to reduce harm related to alcohol.76

5.1.4 Studies indicate that harmful drinkers are more likely to drink cheap alcohol

than moderate consumers of alcohol. There is also evidence to suggest that

risky alcohol consumption among young people is strongly related to

disposable income.77 Thus, it is likely that increases in price would reduce

alcohol consumption in both young people, and in heavier drinkers.

5.1.5 Minimum pricing is considered by the WHO to be one of the most cost-

effective actions to reduce alcohol consumption in populations with

moderate or high levels of drinking. This is based on analysis and costing of

a range of interventions, including education, advertising and drink driving

legislation.78

5.1.6 In the UK, extensive research has been done by the Sheffield Alcohol Policy

group on minimum pricing, including studies commissioned by the English

and Scottish Governments on the implementation of minimum pricing

policies in their jurisdictions. Despite the fact that the process has stalled

in both England and Scotland at the time of writing this policy statement,

there is a wealth of research which supports both the principle of minimum

pricing and offers insights on implementation of such a model. In Ireland, a

health impact assessment was being commissioned at the time of writing to

study the impact of different minimum prices on a range of areas such as

health, crime and likely economic impact, in conjunction with Northern

Ireland.

5.1.7 Recent evidence from British Columbia, Canada showed that between 2002

and 2009, introduction of minimum pricing reduced the percentage of

alcohol-related deaths, with a reduction already seen only 1 year after the

minimum price increases came into effect.79 Introduction of minimum

pricing in Saskatchewan province in Canada also reduced alcohol

consumption, with a 10 per cent increase in minimum price associated with

an 8.4 per cent reduction in total consumption.80

5.1.8 In Ireland, there is public support for minimum pricing. In a recent Health

Research Board (HRB) survey, almost 58 per cent of respondents agreed that

there should be a minimum price below which alcohol cannot be sold and

19


over 35 per cent of respondents said they would decrease the amount they

purchase in response to a ten per cent price increase.81

5.1.9 Critics of the minimum pricing model argue that a minimum price for

alcohol would affect those on low incomes disproportionately. However, it

should be remembered that people on low incomes often suffer from a

range of health inequalities that can be made worse by alcohol use.

5.1.10 It is the opinion of the RCPI policy group on alcohol that minimum pricing

should not affect the price of drinks in the on-trade sector. The sale of

alcohol in the controlled environment of bars and restaurants is less of a

concern than the cheap alcohol sales from the off-trade. Instead, minimum

pricing will target off-trade sales where the cheapest alcohol is sold.

5.2 Reduced Availability

We support measures to reduce the availability of alcohol.

5.2.1 It is the opinion of the RCPI Policy Group on Alcohol that alcohol should be

made less available, through both the introduction of new legislation and

controls and through stricter enforcement of existing controls. We propose

that there should be a reduction in the number of outlets where alcohol can

be purchased. There should also be stricter controls on alcohol promotions

and the placement of alcohol in mixed retail outlets.

5.2.2 Studies from both Finland and Sweden showed linkages between alcohol-

related harm and the number of outlets selling alcohol.82 In Ireland, the

increase in recent years in the number of off-licences is of particular

concern. We support the recommendation of the NSMS report that the HSE

should be allowed to object to the granting of new licences/ renewal of

licences. To date these matters have been dealt with from a criminal

justice perspective but this recommendation emphasises that alcohol and

the harm it causes is a health issue as well.

5.2.3 There is a need for off-trade outlets to manage alcohol sales more

responsibly. The proliferation of alcohol promotions encourages increased

consumption83 and thus sales promotions and discounts should be more

strictly controlled. We support the NSMS report recommendation that a

20


statutory code of practice on the sale of alcohol in the off-trade sector be

introduced.

5.2.4 The placement of alcohol in mixed retail outlets alongside groceries gives

the impression that alcohol is an ordinary commodity, and normalises

alcohol as part of a weekly shopping list. In the long term, we are in favour

of alcohol only being sold in specialist off-licences. In the short term, we

support of the idea that in mixed retail outlets alcohol should only be sold

in zoned areas. We recommend commencement of Section 9 of the

Intoxicating Liquor Act 2008 which provides for structural separation of

alcohol products from other beverages and food products in premises which

are engaged in mixed trading, such as supermarkets, convenience stores

and petrol stations. A voluntary code of practice which includes reference

to structural separation has meant that some outlets have implemented

structural separation, but this is not widespread.

5.2.5 Because of the health impact on alcohol and young people, sale and supply

to minors should not be tolerated. There should be punitive fines with

rigorous implementation and oversight for sale and supply to minors.

5.2.6 There are a range of measures to further counter drink-driving outlines in

the NSMS report. The Irish Government’s approach to drink driving, both in

the previous and in the current Government, is exemplary and has resulted

in a reduction in the loss of life on our roads to a substantial degree. The

RCPI Policy Group on Alcohol commends the Department of Transport on its

initiatives over the years in relation to drink driving. The diligent action in

this sphere shows that culture can change with leadership.

5.3 Changing Culture

We support measures to change the culture of excessive alcohol consumption.

5.3.1 The RCPI Policy Group on Alcohol is of the view that the cultural acceptance

of excessive alcohol consumption in Ireland is an issue which needs to be

addressed urgently. Though awareness campaigns and education on alcohol

are not the most cost-effective methods of reducing alcohol consumption,

they have a role to play in challenging the culture of alcohol in Irish society.

21


Of more concern however, are the advertising and marketing campaigns

which especially influence young people.

5.3.2 Advertising and marketing of alcohol encourage people to consume alcohol

and contribute to a culture of acceptability in relation to excessive alcohol

consumption. There is evidence to suggest that alcohol marketing is linked

to youth drinking initiation and continued drinking.84 Recent analysis

showed that younger people (10-15 years) in the UK are much more exposed

to alcohol marketing than adults, and we believe the same is true for

younger people in Ireland.85 Taking this into account, stricter controls

should be introduced on where and when alcohol advertising is placed, with

a view to limiting exposure of minors to alcohol marketing. This applies to

outdoor advertising, traditional media advertising, and new media

advertising. We support the recommendations of the NSMS report in relation

to a statutory framework with provisions on alcohol advertising to address

this issue.

5.3.3 We believe that in particular, alcohol sponsorship in sport should no longer

be the norm. Alcohol is a drug, and as such can no longer be perceived as a

normal component of sporting activity. The RCPI Policy Group on Alcohol is

of the view that alcohol sponsorship of sports events and organisations

should be phased out. This phasing out in the first instance should provide

for a ban on all new sponsorship arrangements being put in place. The

existing arrangements need a stepped approach towards eventual cessation.

5.3.4 These are the recommendations of the National Substance Misuse Steering

Group that have been the most controversial. The alcohol industry has a

very powerful voice in Ireland and the contribution of this industry to

sporting and cultural events is substantial. Many arguments for continued

alcohol sponsorship point to the potential financial gap which sporting

organisations would suffer if alcohol sponsorship was no longer allowed.

This argument does not allow for the fact that there may be other (non

alcohol-related) sponsors who would be interested in the marketing

opportunity that this gap would create.

5.3.5 Although drinks companies who sponsor sporting events deny that alcohol

sponsorship serves to increase alcohol consumption, the evidence is that it

does. An analysis of 13 longitudinal studies involving 38000 young people led

the authors to conclude that alcohol advertising and promotion increases

22


the likelihood that adolescents will start to use alcohol, and to drink more if

they are already using alcohol.86 Also, from Australia there is evidence that

sportspeople exposed to alcohol sport sponsorship had higher drinking

scores.87

5.3.6 Other commercial sponsors of sport in Ireland should be actively pursued

and the Government needs to examine the degree to which the State will

accept responsibility for the funding of sport and culture in Ireland.

5.3.7 Although this is a controversial issue, there is indication that there is

sizeable public support for the ending of alcohol sponsorship of sports; 42

per cent support this, according to the HRB survey previously mentioned.88

5.4 Alcohol Consumption Guidelines

We support dissemination of guidelines on low-risk levels of alcohol consumption.

5.4.1 The HRB report on attitudes to alcohol indicates that knowledge of standard

drink measures and weekly low-risk consumption amounts is weak. Less

than one in ten respondents were clear on the number of standard drinks in

four different alcoholic drinks of various measures or the recommended

weekly number of standard drinks for men and for women.89 There is an

important public health information campaign required to increase public

knowledge as a prelude to behaviour change. Education campaigns, which

are mentioned in the NSMS recommendations, together with more

appropriate labeling, can help individuals to make more informed choices.

5.4.2 There is some personal responsibility in relation to alcohol consumption and

while Government can regulate and make the environment less conducive

to alcohol-related harm than it currently is, there is an onus on individuals

to change. Better information from health sources will help individuals

make more informed choices as will a restriction on information from

commercial sources.

5.4.3 The Royal College of Physicians of Ireland supports the stated weekly low-

risk guidelines of 11 standard drinks per week (112 grams of pure alcohol)

for women and 17 standard drinks per week (168 grams of pure alcohol) for

men, as outlined in the NSMS report. The RCPI also supports the recent

advice from the Department of Health that people should not consume

23


alcohol at levels greater that these weekly low-risk guidelines; that they

should spread their drinks out over the week; that they should not consume

more than 5 standard drinks in any one sitting; and that they should have at

least 3 alcohol-free days during the week.

5.4.4 RCPI will also play its part in developing and implementing more detailed

clinical guidelines and clinical information to provide extra information for

the population in interpreting these guidelines.

5.4.5 We also support the NSMS recommendation that labels on alcohol products

sold in Ireland should include the number of both units of alcohol and grams

of alcohol per container, calorific content and health warnings, particularly

in relation to consuming alcohol in pregnancy.

6 The Solutions - Medical Supports

There are a number of areas within our Health System where targeted actions can

support alcohol harm reduction.

The RCPI policy group on Alcohol believes that investment in alcohol services

within the Health System will reap financial savings in the long term. Although

some of the solutions will be costly, the costs of implementing any of these

changes need to be balanced against the cost of alcohol treatment, and the

societal costs of alcohol.

6.1 Alcohol Screening and Brief Interventions

We propose that Alcohol Screening and Brief Interventions be embedded in clinical

practice.

6.1.1 Much of the treatment for alcohol-related problems has focused on

individuals who are alcohol dependent. Alcohol-related harm however is not

limited to this group, and there is a need to broaden the focus of alcohol

services to include drinkers who may not be alcohol dependent, but who

consume alcohol in a harmful/hazardous manner.

6.1.2 Early detection of harmful and hazardous drinkers can be facilitated by

seeking detailed alcohol history from patients who present with conditions

24


or injuries associated with alcohol misuse. This early detection could lead

to a reduction in the number of patients progressing to severe alcohol-

related harms.

6.1.3 Brief Interventionsvi are interventions for hazardous drinkers who consume

alcohol at levels at which they risk experiencing associated problems.

Generally, Brief Interventions are aimed at those hazardous drinkers who

may not have symptoms of alcohol dependence. They are short and cheaper

to implement than conventional specialist alcohol treatments. A Brief

Intervention usually comprises assessment of alcohol consumption and

provisions of information on harmful drinking to the individual, including

booklets and information on local services.90

6.1.4 Screening involves identifying people who do not specifically present to

health services for alcohol-related problems, but who may be consuming

alcohol at harmful/hazardous levels. Various screening methodologies have

proven to be useful including the WHO Alcohol Use Disorders Identification

Test (AUDIT). This test is administered by means of a questionnaire

containing 10 questions on frequency and intensity of drinking. Based on

responses, an individual’s risk can be categorised from low risk through to

possible dependence. 91

6.1.5 Screening can be conducted by various methods, but the AUDIT

questionnaire is considered to be one of the most suitable for use in the

general hospital. One advantage is that it can be easily incorporated into a

lifestyle questionnaire which shifts the focus towards public health and

management of the whole patient.92 Other tests include the Paddington

Alcohol Test, and the Fast Alcohol Screening Tests (FAST).

6.1.6 Indications are that the general public would welcome such screening.

According to the HRB report on alcohol attitudes “there is near complete

support (95 per cent or over) for healthcare professionals asking about

alcohol consumption where it is linked to the patient’s condition or

treatment”. 93

6.1.7 Although screening and BIs are an effective way of dealing with harmful

drinkers, there are currently no formal guidelines for screening and BIs in

vi Sometimes referred to as brief advice

25


acute hospitals in Ireland. RCPI supports the recommendation of the NSMS

report that clear guidelines should be developed and implemented across

all acute hospitals and other relevant sectors of the health system.

6.1.8 The RCPI Policy Group on Alcohol recommends that screening for hazardous,

harmful and dependent drinking should be embedded into clinical care to

allow for early identification of hazardous/harmful and dependent drinkers.

It should be linked to the provision of brief intervention by trained health

care workers in a primary care setting. Follow up and extended brief advice

should be offered to those patients not responding to brief interventions.

Those people with continuing problems or with dependence should be

referred to specialist treatment centres.

6.1.9 There should also be adequate access to tier two, three and four alcohol

services for those patients not responding to brief intervention. In

particular, tier three services are required where medically assisted

withdrawal from alcohol can be provided on an out-patient basis.

6.1.10 RCPI supports the recommendations of the NSMS report with respect to

inclusion of a specific module on screening and brief interventions for

different health service providers.

6.2 Integrated Model of Care

We recommend that an integrated model of care be developed for treatment of

alcohol-related health problems.

6.2.1 There is an urgent need to develop clinical guidelines/standards/protocols

for healthcare professionals across all relevant sectors of the health and

social care system for treatment of alcohol-related health problems.

6.2.2 Most alcohol treatment programmes are now community rather than

hospital based. Unfortunately, the links between the hospital and the

community based programmes are almost non-existent. Typically, a patient

leaving hospital will be given a list of community programmes in their

locality or asked to contact their general practitioner to arrange referral.

There is no structure in place for the alcohol treatment programme to

receive information relating to the in-patient care. Similarly, hospital-

based consultants never receive reports or updates on mutual patients from

the alcohol services. Some hospitals employ alcohol or addiction nurses one

26


of whose duties is to improve communication between the service

providers. In other institutions social workers perform that role. Many

patients commit to abstinence in hospital and it is a pity if that momentum

is lost following discharge. Efforts are thus needed to strengthen links

between the hospital and the community.

6.2.3 Many alcohol dependent patients who are admitted for treatment to

hospital and or diagnosed with alcoholic liver disease are in need of post

discharge supervision and support. Without this supervision and support,

many patients return to former drinking patterns, default on follow up and

re-present as emergencies with liver failure.

6.2.4 Recognising the vital role that community services play in alcohol

treatment, RCPI recommends that services providing after care in the

community should be supported and improved, particularly with respect to

relapse prevention.

6.2.5 At present the referral relationship between primary and secondary care

needs to be improved.

6.2.6 There is a need for outpatient detoxification services to be established

under the auspices of addiction services.

6.2.7 Alcohol-related mental illness should be included within the model of care.

RCPI recommends implementation of the recommendations in A Vision for

Change 94 in relation to establishing clear linkages between the addiction

services, primary care services, community mental health teams and

specialist mental health teams.

6.2.8 All acute hospitals should have an alcohol team led by a consultant or senior

nurse, and incorporating at least one alcohol nurse specialist. This will lead

to improvements in screening and Brief Intervention, improved management

of acute alcohol withdrawal and will provide for better follow up and links

between acute hospitals and the community.

6.2.9 Treatment of alcohol liver disease should be centralised to improve

prognosis. There is a large literature showing that in many surgical and

medical conditions outcomes depend on hospital volume. Based on this

evidence, it is the opinion of the RCPI policy group on alcohol that patients

with advanced stage alcoholic liver disease would benefit from centralised

treatment.

27


6.3 Research Funding

We recommend that the Government allocate specific funding for research into

alcohol-related harms, especially alcoholic liver disease.

6.3.1 There is very little funding available for research into alcohol-related harm,

especially alcoholic liver disease. Despite the high associated mortality for

alcoholic liver disease, it is an unpopular subject with funding bodies, and

as a result, there have been no advances in treatment and no new drugs

have been developed.

6.3.2 We therefore call on the Government to allocate specific funding for

research into alcohol-related harms. Based on the polluter pays principle,

the Government should use social responsibility levies on the alcohol

industry to support this research. It is important to emphasise however,

that any research conducted should be independent of the alcohol industry,

and the funds should be spent on front-line research; both clinical and

epidemiological.

28


7 Members of the RCPI Policy Group on Alcohol

The membership of the RCPI Policy Group on Alcohol is as follows:

Members Institution

CHAIR

Prof Frank Murray

Beaumont Hospital Dublin & Royal College of Physicians of Ireland

(RCPI)

MEMBERS

Prof Joe Barry Faculty of Public Health Medicine, RCPI

Dr Turlough Bolger Faculty of Paediatrics, RCPI

Dr Thomas Breslin Irish Association for Emergency Medicine

Dr William Flannery The College of Psychiatry of Ireland

Dr Blanaid Hayes Faculty of Occupational Medicine, RCPI

Dr Fenton Howell Clinical Lead, Chronic Disease Prevention Programme

Dr Marie Laffoy National Cancer Control Programme

Prof Aiden McCormick Irish Society of Gastroenterology

Prof Deirdre Murphy Institute of Obstetricians and Gynaecologists, RCPI

Dr Brian Norton Irish College of General Practitioners

Dr Kieran O’Shea Institute of Orthopaedic Surgery

Dr Eimear Smith Irish Association for Rehabilitation Medicine

Dr Steven Stewart Centre for Liver Disease Mater Misericordiae Hospital

Prof William Tormey Faculty of Pathology, RCPI

Prof Michael Walsh Irish Cardiac Society

Further information relating to this position paper, and the members of the policy

group , please contact the Royal College of Physicians of Ireland at www.rcpi.ie or

at +353 1 8639700.

http://www.rcpi.ie/

29


8 Appendix- Factsheet on Alcohol Health Harm

What is the Problem?

“We are seeing different health problems emerging; frequently the

cause is our modern lifestyle. This trend is worrying and unless we

make some significant changes, we are facing an unhealthy and costly

future”. (An Taoiseach Enda Kenny, Healthy Ireland Framework 2013-

2015)

Excessive alcohol consumption is embedded in Irish society.

Drinking alcohol in the pub is an important aspect of Irish community and social life. The same does not apply for alcohol from off-licences.

Alcohol consumption per capita at 11.9L is higher than the European Average of 10.7L, and 6th highest in the EU. This is much higher than consumption target of the Healthy Ireland Framework of 9.2L.

Ireland has a higher prevalence of binge drinking than any other European country, with the highest percentage of binge drinkers in the 18-29 age groups.

Binge drinking is increasing among 18-23 yr olds.

Since 2001 when consumption peaked at 14.2L, alcohol consumption has been decreasing but alcohol consumption per capita has almost doubled since 1963.

Alcohol consumption in Ireland per capita increased by 24% between 1980 and 2010 while during this period, the European average decreased by 15%.

A relatively high number of abstainers and a high prevalence of binge drinking indicate an inability to adopt a moderate consumption pattern.

Higher proportion of Irish women drink compared with women in other European countries (77% compared to 68%).

The average Irish person spends approximately €2000 per year on alcohol.

Excessive alcohol consumption is directly related to health harm.

88 deaths every month in Ireland are directly attributable to alcohol.

Between 2004 and 2008, alcohol caused nearly twice as many deaths as all other drugs combined.

Alcohol is a major contributing factor in suicide in Ireland – study shows that more than half of people who died from suicide had alcohol in their blood.

Disease and health service utilisation:

o Even at relatively low levels of consumption, alcohol increases the risk of many types of cancer.

o Mortality related to cirrhosis, the commonest cause of which is alcohol, doubled from 1994 to 2008.

30


o Between 1995 and 2007, hospital admissions for liver disease increased by 191%.

o 72 % of deaths from alcoholic liver disease were in patients <65yrs old.

o Alcoholic liver disease becoming more common in younger people.

o Alcohol-related disorders accounted for 1 in 10 first admissions to Irish psychiatric hospitals in 2011.

o 1 in 4 injuries presenting to A&E departments are related to alcohol.

o Drinking alcohol while pregnant can cause a range of birth defects and intellectual impairments in the unborn child (Foetal Alcohol Spectrum Disorders).

o Because the brain in still developing, drinking in adolescence has the potential to cause detrimental effects, including neurocognitive impairment.

Excessive alcohol consumption has various family and social harms.

The health harms are only part of the problem related to alcohol. There are wider personal and family impacts which have a negative effect on the individual and on society:

Excessive alcohol use frequently leads to unsafe sex resulting in unplanned pregnancies and sexually transmitted diseases.

16% of child abuse and neglect cases are associated with adult alcohol problems and 1 in 11 Irish children are negatively impacted by a parent’s drinking.

Alcohols abuse is a factor in martial disharmony and break-up and in cases of domestic violence.

From 2003 to 2005, over half of all drivers fatally injured in Road Traffic Accidents in Ireland had alcohol in their blood.

For younger people, early onset alcohol use increases the risk of problem alcohol and drug use later in life.

Alcohol costs the state vast amounts of money and resources.

Approximately 2000 beds every night in Irish Hospitals.

Costs to the health system were estimated at €1.2bn in 2007.

Alcohol-related crime costs the state €1.19bn (2007 estimates).

Total cost in 2007 was estimated at €3.7bn. This is 1.9% of total GNP.

Excessive alcohol consumption impacts work performance and is frequently the cause of absenteeism and physical injuries in workplace.

Despite the high societal and economic cost of problem alcohol use in Ireland,

actions to reduce alcohol consumption and to address harmful drinking patterns

have, to date, been limited. The Royal College of Physicians of Ireland believes

that there are proven solutions to this problem which should be implemented

immediately for the benefit of the individual and for society in general.

31


What are the proposed solutions?

Societal/Public Health Solutions

From a societal perspective, there are four areas where concrete, immediate actions could be put in place to limit alcohol consumption, thereby reducing alcohol-related harm.

We support the introduction of minimum pricing to prevent the sale of cheap alcohol.

We support this recommendation of the Steering Group Report on a National Substance Misuse Strategy (NSMS).

This is considered by the World Health Organisation to be one of most cost-effective actions to reduce excessive alcohol consumption.

Studies show minimum pricing works - evidence from minimum pricing implemented in Canada showed reduction in deaths within 1 year.

In Ireland excise increases in 2003 and 2002 on spirits and cider respectively, showed a corresponding decrease in consumption.

A recent HRB survey indicates public support for minimum pricing.

Minimum pricing will not affect the price of pint in the pub. Rather it will target off-trade sales where the cheapest alcohol is sold.

We support measures to reduce the availability of alcohol.

Number of alcohol outlets should be reduced. The recommendation from NSMS report to allow HSE to object to the new licences/ renewal of licences should be implemented.

Alcohol sales in off-trade outlets should be managed better and low cost sales promotions and discounts should be strictly controlled.

Alcohol should be sold in zoned areas in mixed retail outlets.

Sale and supply to minors should not be tolerated and there should be punitive fines with rigorous implementation and oversight for this.

We support measures to change the culture of excessive alcohol consumption.

Alcohol advertising/marketing encourages people, particularly younger people to consume alcohol and contributes to a culture of acceptability in relation to excessive alcohol consumption.

Alcohol sponsorship of sports events and organisations should be phased out.

Stricter controls should be introduced on where and when alcohol advertising is placed, with a view to limiting exposure of minors to alcohol marketing.

We support dissemination of guidelines on low-risk levels of alcohol

consumption.

There is weak knowledge of standard drink measures and weekly low-risk consumption amounts.

We support the NSMS stated guidelines for low-risk alcohol consumption and the recommendation on labeling of alcohol products sold in Ireland.

32


Medical Supports

There are a number of areas within our Health System where targeted actions can

support alcohol harm reduction:

We propose that Alcohol Screening and Brief Interventions be embedded in

clinical practice.

Although screening and Brief Interventions are an effective way of dealing with harmful drinkers, there are currently no formal guidelines for screening and BIs in acute hospitals.

Screening for hazardous, harmful and dependent drinking should be embedded into clinical care.

Screening should be linked to the provision of brief intervention/brief advice by trained health care workers.

There should be adequate access to tier two, three and four alcohol services for patients not responding to brief interventions.

We recommend that an integrated model of care be developed for treatment of

alcohol-related health problems.

There is an urgent need to develop clinical guidelines/standards/protocols for healthcare professionals across all relevant sectors of the health and social care system.

Efforts are needed to strengthen links between the alcohol treatment services in hospitals and the community.

Aftercare in the community should be supported and improved, particularly with respect to relapse prevention.

The referral relationship between primary and secondary care needs to be improved.

There is a need for outpatient detoxification services to be established.

Alcohol-related mental illness should be included within the model of care.

Acute hospitals should have an alcohol team led by a consultant or senior nurse, and incorporating at least one alcohol nurse specialist.

Funding

We recommend that the Government allocate specific funding for research into

alcohol-related health harms, especially alcoholic liver disease.

There is very little funding available for research into alcohol-related health harms, especially alcoholic liver disease.

Dedicated funding is needed for independent front-line research in this area.

The Government should use levies on the alcohol industry to support this research.

33


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